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14 Other Approaches forReducing Surgical Risk
223© Springer International Publishing AG 2018
K.A. Delman, V.A. Master (eds.), Malignancies of the Groin,
https://doi.org/10.1007/978-3-319-60858-7_15
Chapter 15
Surgical andAnatomic Considerations
ofMalignancies Affecting theGroin:
Reconstructive Approaches totheGroin
SeyedAmirhosseinRazavi, KaranA.Desai, AlbertLiao, andAlbertLosken
There has been an increasing demand for reconstructive surgery in acute or chronic
groin wounds resulting from burn, trauma patients with oncologic defects following
groin lymphadenectomy due to urogenital and lower limb malignancies and compli-
cations of infrainguinal vascular bypass surgeries [1–6]. The reconstructive surgeon
has to select the optimal soft tissue coverage after considering the patient’s comor-
bidities, postoperative quality of life, and functional outcome. In this chapter, we
will review the reconstructive options regarding complex wounds in the inguinal
region, a brief description of the reconstructive technique, reported outcomes, and
comparison between options including use of grafts and aps.
Primary Closure
Primary closure is always preferred when possible due to lower morbidity. Using
the reconstructive ladder as a guideline, primary reconstruction is the most direct
form of reconstruction and can be used in a variety of traumatic wounds and skin
cancer excisions [7, 8]. Primary closure however is often not possible in wounds
that are wide and have been previously irradiated.
S.A. Razavi, M.D. • K.A. Desai, M.D. • A. Liao, M.D.
A. Losken, M.D., F.A.C.S. (
*)
Division of Plastic Surgery, Department of Surgery,
Emory University Hospital Midtown, Emory University School of Medicine,
Medical Ofce Tower, 550 Peachtree Street, SE Suite 9000, Atlanta, GA 30308, USA
e-mail: srazavi@emory.edu; karan.desai@emory.edu; albert.liao@emory.edu;
alosken@emory.edu
224
Skin Graft
Skin graft is the transfer of skin from a donor site to a recipient site. When primary
closure is not possible secondary to a large defect, a skin graft may be used. In con-
trast to ap reconstruction, skin grafts develop their blood supply by neovascular-
ization during the rst 48–72 h after transfer. Two types of skin grafts are
split- thickness and full-thickness skin grafts. Full-thickness skin grafts require more
time for revascularization but have less wound contracture prole. In general, full-
thickness skin grafts do not have a role in groin reconstruction secondary to the
overall large size of the wounds requiring coverage. Groin wounds are most often
covered by split-thickness skin grafts from the thigh, buttocks, or trunk and will
subsequently heal by epithelialization [8–10]. While split-thickness skin grafts are
versatile, their use is restricted in the presence of wounds with exposed vital struc-
tures such as bones, nerves, or femoral vessels. Furthermore, reconstruction of a
radiated groin wound requires coverage with a well-vascularized tissue to prevent
wound-healing complications. In these situations, the clinician should seek more
complex methods in the reconstructive ladder such as ap reconstruction [2, 11, 12].
Skin grafts are often used if a wound has been slow to heal and otherwise has a
healthy granulation bed or is a supercial defect with a well-vascularized layer sub-
cutaneous tissue above the vessels.
Flap Reconstruction
Flap reconstruction is the transfer of skin and underlying tissue, when it is lifted from
a donor site and moved to a recipient site with its blood supply. Pedicled aps have
their vascular supply connected anatomically throughout the ap transfer. Free aps
on the other hand are when vascular supply is disconnected from its donor supply dur-
ing transfer and reconnected microsurgically to a new vessel at or near the recipient
site. The free aps are often used when no local or pedicle ap is available.
Flap closures are particularly useful for a wound bed with compromised tissue
such as in infected or radiated wounds with exposed structures. They provide protec-
tion over exposed bones, nerves, or vessels in the wound; increase vascularization to
decient areas; decrease scar formation; and result in a tension-free closure [2, 13].
The main complication associated with ap reconstruction is the risk of vascular
compromise. When feasible, pedicled aps are always preferred over free aps.
Frequent postoperative ap checks including monitoring ap color, temperature,
capillary rell, appearance, and use of tissue oximetry and external and implantable
Dopplers are necessary for early diagnosis of ap vascular compromise [14–16].
Other potential complications of ap reconstruction include hematoma and seroma
formation, surgical site infections, and donor site complications.
There are many different local ap options for groin reconstruction, including
gracilis muscle ap (medial femoral circumex system), sartorius muscle ap
S.A. Razavi et al.
225
(supercial circumex iliac artery from the supercial femoral artery), omental ap
(right omental artery from the right gastroepiploic artery), tensor fascia lata ap
(ascending branch of lateral femoral circumex artery), anterolateral thigh ap
(descending branch of lateral femoral circumex artery), rectus abdominis ap
(deep inferior epigastric artery), and rectus femoris ap (descending branch of lat-
eral femoral circumex artery) (Figs.15.1 and 15.2).
abc
Fig. 15.1 Rectus myocutaneous ap reconstruction of right groin oncologic defect with exposed
vessels. (a) Pre-reconstruction, (b) post-reconstruction, (c) rst follow-up in the plastic surgery clinic
a b
Fig. 15.2 Another example of rectus myocutaneous ap reconstruction. (a) Pre-reconstruction,
(b) post-reconstruction
15 Surgical andAnatomic Considerations ofMalignancies Affecting theGroin
226
Regional muscle aps such as the gracilis muscle ap and the sartorius muscle
ap are usually useful for reconstruction of small groin defects [17–19]. Sartorius
aps and pedicled gracilis aps are safe and durable reconstructions for locally
infected or exposed vascular grafts and infected groin wound of <10cm. However,
as these aps consist only of muscle, a skin graft is often needed over the ap for
skin coverage in the event of a skin decit. In their retrospective review of 244 aps
used for complex groin wound reconstruction, Fischer etal. suggested the use of
prophylactic sartorius muscle ap for smaller, low-risk wounds, reserving rectus
femoris ap for larger, more complex wounds and anterolateral thigh for wounds
with larger cutaneous defect [20].
A retrospective review by Ducic and colleagues for the use of extended dissection
gracilis ap in high-risk patients with complex groin wounds requiring more coverage
than a standard gracilis ap concluded that the extended dissection gracilis ap has
greater arc of rotation and no restriction on postoperative ambulation or thigh abduc-
tion [21]. First described by Hason etal. [22] in the extended dissection gracilis ap
technique, after the identication of the pedicle, the muscle is divided proximally, and
pedicle dissection continues deeper to the adductor longus muscle, the perforators, and
the vascular network and can be extended all the way to the profunda femoris artery.
There does not appear to be a consensus rst choice ap option for large (>10cm)
groin defects; however, anterolateral thigh (ALT) ap (both as a pedicled and free
ap) and vertical rectus abdominis myocutaneous ap are considered highly versa-
tile and reliable for this type of defect [3, 7, 23]. In their retrospective review,
Lannon etal. determined that the pedicled ALT ap should be the ap of choice for
large groin defects. There are several techniques to preserve ap viability, including
suprafascial ap harvesting, extended harvesting of fascia, utilization of the fascia
to protect the pedicle, coharvest with the vastus lateralis, and preservation of large
lateral rectus femoris perforators [23].
A retrospective review by LoGiudice etal. looking at 39 patients who underwent
reconstruction with ALT ap and rectus abdominis ap demonstrated shorter time
to healing and lower rate of delayed postoperative complications in the ALT group.
Incisional hernias were of particular concern in rectus abdominis ap patients [4].
Aslim etal. [3] reported their use of ALT ap and vertical rectus abdominis muscu-
locutaneous (VRAM) ap for large groin defects, both resulting in consistent results
with little morbidity. Additionally, both aps have the benet of having donor sites
that can be closed primarily reducing donor site morbidity.
A review of 50 patients, who underwent VRAM (63%) and extended RAM
(37%) aps by Parrett etal., showed reliable coverage of irradiated thigh and groin
oncologic wounds. Extended RAM was used for contralateral and more distal
defects. Parret reported signicantly improved results when performing immediate
compared to delayed reconstruction [5].
Comparing vertical and oblique RAM aps in 71 patients, Combs and colleagues
reported similar complication rates between the two reconstruction techniques.
They concluded that an oblique RAM ap is a safe alternative to VRAM with
advantages including greater arc of rotation, thinner skin paddle, less bulk, and lim-
ited fascial harvest [24].
S.A. Razavi et al.
227
Alkon etal. [25] reviewed their experience with rectus femoris muscle aps as
an effective and reliable mean for complex groin wound reconstruction. This ap is
harvested through a mid-anterior incision extending over the distal two-thirds of the
thigh, with muscle elevated on its pedicle and transposed into the groin wound
defect. They reported no ap losses and no donor site complications in the 37 rectus
femoris aps performed between 1999 and 2003. Reoperation was required in four
patients, one for ap readvancement and three for prosthetic vascular graft removal.
A cost analysis study by Chatterjee and colleagues comparing sartorius (n=234)
versus rectus femoris (n= 62) ap in the treatment of the infected vascular groin
graft wounds notes that the rectus femoris ap is the more cost-effective option with
less major complication prole [26].
In conclusion, evaluation for complex groin wound reconstruction starts with
considering patients’ comorbidities, postoperative quality of life, and functional
outcome and going through the reconstructive ladder. The reconstructive surgeon
should always consider primary reconstruction and skin grafting as rst options and
then move to more complex reconstruction options such as pedicled and free aps.
The gracilis and sartorius aps are useful options for reconstruction of smaller,
low-risk groin wounds (<10cm), while anterolateral thigh ap and vertical rectus
abdominis myocutaneous ap are reliable options for reconstruction of larger groin
defects.
References
1. Horch R, Stark GB.Prosthetic vascular graft infection--defect covering with delayed vertical
rectus abdominis muscular ap (VRAM) and rectus femoris ap. Vasa. 1994;23:52–6.
2. Murthy V, Gopinath KS.Reconstruction of groin defects following radical inguinal lymphad-
enectomy: an evidence based review. Indian JSurg Oncol. 2012;3:130–8.
3. Aslim EJ, Rasheed MZ, Lin F, Ong YS, Tan BK.Use of the anterolateral thigh and vertical
rectus abdominis musculocutaneous aps as utility aps in reconstructing large groin defects.
Arch Plast Surg. 2014;41:556–61.
4. LoGiudice JA, Haberman K, Sanger JR.The anterolateral thigh ap for groin and lower
abdominal defects: a better alternative to the rectus abdominis ap. Plast Reconstr Surg.
2014;133:162–8.
5. Parrett BM, Winograd JM, Garfein ES, Lee WP, Hornicek FJ, etal. The vertical and extended
rectus abdominis myocutaneous ap for irradiated thigh and groin defects. Plast Reconstr
Surg. 2008;122:171–7.
6. Perez-Burkhardt JL, Gonzalez-Fajardo JA, Carpintero LA, Mateo AM. Sartorius myo-
plasty for the treatment of infected groins with vascular grafts. JCardiovasc Surg (Torino).
1995;36:581–5.
7. Larson JD, Altman AM, Bentz ML, Larson DL.Pressure ulcers and perineal reconstruction.
Plast Reconstr Surg. 2014;133:39e–48e.
8. Simman R. Wound closure and the reconstructive ladder in plastic surgery. JAm Col Certif
Wound Spec. 2009;1:6–11.
9. Ratner D.Skin grafting. Semin Cutan Med Surg. 2003;22:295–305.
10. Ogawa R, Hyakusoku H, Ono S.Useful tips for successful skin grafting. JNippon Med Sch.
2007;74:386–92.
11. Fujioka M.Surgical Reconstruction of Radiation Injuries. Adv Wound Care (New Rochelle).
2014;3:25–37.
15 Surgical andAnatomic Considerations ofMalignancies Affecting theGroin
228
12. Payne WG, Walusimbi MS, Blue ML, Mosiello G, Wright TE, etal. Radiated groin wounds:
pitfalls in reconstruction. Am Surg. 2003;69:994–7.
13. Schoeman BJ.The tensor fascia lata myocutaneous ap in reconstruction of inguinal skin
defects after radical lymphadenectomy. S Afr JSurg. 1995;33:175–8.
14. Lin SJ, Nguyen MD, Chen C, Colakoglu S, Curtis MS, etal. Tissue oximetry monitoring in
microsurgical breast reconstruction decreases ap loss and improves rate of ap salvage. Plast
Reconstr Surg. 2011;127:1080–5.
15. Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R.A prospective analysis of free ap
monitoring techniques: physical examination, external Doppler, implantable Doppler, and tis-
sue oximetry. JReconstr Microsurg. 2013;29:51–6.
16. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M.What should dene a “perforator
ap”? Plast Reconstr Surg. 2010;126:2258–63.
17. Maser B, Vedder N, Rodriguez D, Johansen K.Sartorius myoplasty for infected vascular grafts
in the groin. Safe, durable, and effective. Arch Surg. 1997;132:522–5. discussion 525-526
18. Chen SH, Hentz VR, Wei FC, Chen YR.Short gracilis myocutaneous aps for vulvoperineal
and inguinal reconstruction. Plast Reconstr Surg. 1995;95:372–7.
19. Shih PK, Cheng HT, Wu CI, Chang SC, Chen HC, etal. Management of infected groin wounds
after vascular surgery. Surg Infect (Larchmt). 2013;14:325–30.
20. Fischer JP, Mirzabeigi MN, Sieber BA, Nelson JA, Wu LC, et al. Outcome analysis of
244 consecutive aps for managing complex groin wounds. JPlast Reconstr Aesthet Surg.
2013;66:1396–404.
21. Ducic I, Dayan JH, Attinger CE, Curry P.Complex perineal and groin wound reconstruc-
tion using the extended dissection technique of the gracilis ap. Plast Reconstr Surg.
2008;122:472–8.
22. Hasen KV, Gallegos ML, Dumanian GA. Extended approach to the vascular pedicle of the
gracilis muscle ap: anatomical and clinical study. Plast Reconstr Surg. 2003;111:2203–8.
23. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, etal. Versatility of the proximally
pedicled anterolateral thigh ap and its use in complex abdominal and pelvic reconstruction.
Plast Reconstr Surg. 2011;127:677–88.
24. Combs PD, Sousa JD, Louie O, Said HK, Neligan PC, etal. Comparison of vertical and
oblique rectus abdominis myocutaneous aps for pelvic, perineal, and groin reconstruction.
Plast Reconstr Surg. 2014;134:315–23.
25. Alkon JD, Smith A, Losee JE, Illig KA, Green RM, et al. Management of complex groin
wounds: preferred use of the rectus femoris muscle ap. Plast Reconstr Surg. 2005;115:776–
83. discussion 784–75
26. Chatterjee A, Kosowski T, Pyfer B, Fisher CS, Tchou JC, etal. A cost-utility analysis compar-
ing the sartorius versus the rectus femoris ap in the treatment of the infected vascular groin
graft wound. Plast Reconstr Surg. 2015;135:1707–14.
S.A. Razavi et al.
229© Springer International Publishing AG 2018
K.A. Delman, V.A. Master (eds.), Malignancies of the Groin,
https://doi.org/10.1007/978-3-319-60858-7_16
Chapter 16
Quality ofLife andOutcomes inPatients
withMalignancies oftheGroin
AndrewJ.Lambour andSandraL.Wong
Introduction
Malignancies of the groin can be generally categorized as primary tumors or as
regional spread of disease to the inguinal lymph nodes. Prognosis and overall sur-
vival are generally related to the natural history of the underlying tumor type as well
as available treatment options. Because of the specic anatomic considerations of
the groin, it is important to note that malignancies of the groin have a serious impact
on the quality of life (QoL) of patients. Oftentimes, this impact occurs as the result
of the uncontrolled or progressive disease process or as the direct result of compli-
cations of treatment for either primary or secondary disease. As such, QoL consid-
erations span the entire continuum of cancer care, including preemptive or primary
operations to longer-term posttreatment effects.
This chapter will provide an overview of QoL, why QoL is important, and how
QoL is measured, as well as touch upon the specics of how certain disease states
impact QoL. The four diseases to be covered in this chapter include melanoma,
penile cancer, soft tissue sarcoma, and vulvar cancer. Related QoL considerations
can include mild symptoms of lymphedema to painful, bulky disease. Generally
speaking, there has been little research on the topic despite the severe implications
that it has on a patient’s overall health.
A.J. Lambour, M.D. • S.L. Wong, M.D., M.S. (*)
Department of Surgery, Dartmouth-Hitchcock Medical Center, Geisel School
of Medicine at Dartmouth, Lebanon, NH, USA
e-mail: Andrew.J.Lambour@hitchcock.org; Sandra.L.Wong@hitchcock.org
230
What Is “Quality ofLife”?
Aristotle’s Nicomachean Ethics provides one of the earliest denitions of quality of
life. In his discourse on happiness, Aristotle states, “what constitutes happiness is a
matter of dispute… some say one thing and some say another, indeed very often the
same man says different things at different times: when he falls sick he thinks health
is happiness, when he is poor wealth.” This in fact informs present-day discussions,
when the World Health Organization (WHO) denes health as “a state of complete
physical, mental, and social well-being, and not merely the absence of disease” [1].
There is actually no consensus as to what constitutes QoL.Much of this stems
from the fact that QoL is inherently subjective and personal. It is because of this
subjectivity that there exists a deep, indescribable sense of what “quality of life” is.
It is ineffable; one may know it when he or she sees it, and physicians may under-
stand it when a patient describes it. QoL is a complex construct, which can be
applied across a variety of contexts. Healthcare-related quality of life (HRQoL) is
the focus herein. Reasonable proposals for evaluating QoL capture the following
areas: general health, physical function, physical symptoms and toxicity, emotional
function, cognitive function, role function, social function, sexual function, and
existentialism. A possibly more parsimonious list includes categories of physical,
emotional, and social aspects of one’s life. Any complete denition or measurement
of QoL would ideally incorporate these dimensions.
Quality of life attributions are subjective—one patient’s perspective on QoL may be
very different from that of another patient. A patient’s quality of life is often affected
by a variety of issues related to their disease. Age, performance status, disease burden,
and tolerance of treatment may inuence a patient’s perspective on QoL.In addition to
this, there is a temporal aspect to QoL that may change as external factors or disease
processes change. Quantifying QoL is truly unlike many of the objective measure-
ments that are obtained in healthcare, such as quantied lab values.
Instruments used to measure QoL attempt to standardize and validate through an
objective and scientic manner. By quantifying QoL, one is able to make comparisons
and track changes over the course of care. Measurement of QoL must be patient driven
though scales used and reported by clinicians should be distinguished from patient-
reported outcomes (PROs)/patient-reported outcome measures (PROMs). The Food and
Drug Administration denes “patient-reported outcomes” as any report of the status of
a patient’s health condition that comes directly from the patient, without interpretation
by a clinician or anyone else. As would be expected, there has been great interest in
PROs/PROMs, but they have yet to be used widely in clinical practice. As such, there are
many methodologic challenges, and currently, there is not enough known about their
reliability and how to aggregate the data for longitudinal measurement of performance.
Why Is Assessment ofQuality ofLife Important?
From its measurement in clinical trials to its impact on treatment decisions, QoL plays
a tremendous role in decision-making around care that is provided to patients. Ultimately,
QoL is one of the major drivers when taking overarching goals of care into account.
A.J. Lambour and S.L. Wong